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Date ran 2/14/2013 9:40:04AR SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by T bagel <br /> Facility Information as of 2/14/2013 <br /> Record Selection Criteria: Facility ID FA0009997 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) $ <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007997 Case Number: H06178 New Owner ID <br /> Owner Name GRIFFEN, STEPHEN <br /> Owner DBA COUNTRY CLUB SERVICE <br /> Owner Address 1403 W COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-474-3141 <br /> Mailing Address 1403W COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009997 tt �� - <br /> Facility Name COUNTRY CLUB SERVIC <br /> Location 1403 W COUNTRY CLUB VD <br /> STOCKTON, CA 95204 <br /> Phone 209-943-3633 <br /> Mailing Address 1403 W COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 12323246 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016997 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name COUNTRY CLUB SERVICE (Circle One) <br /> Account Balance as of 2/14/2013: $2,076.00 <br /> (Circle One) <br /> Transfer to Activennactve <br /> Progra"Element and Description Record ID Employee ID and Name Status Naw Owner? Delete <br /> 1920-HMBP-Common Materials PRO520012 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPRO512285 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2228-GEN 25<50 TONS PERMIT PRO514125 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PRO509997 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0529033 EEOOD4636-GARRETT BACKUS Active,Exempt Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO522966 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO532775 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent ofsame,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form Ialso certify that all operations will be performed in accordance with all applicable Ordinance Cortes anNar Standards and State ender <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Pat�ent Typ Check Number Received by <br /> IQEHS:� ny—Z^ Date L /, /� Account out: �— Date � <br /> COMMENTS: V`V 1— - I/ ,FO <br />